Sample Proof of Service by Facsimile Letter

At the time of the duplicate communication, I was [working in/a resident of] the County of [county name], State of [state name], above the age of eighteen (18) years, and not a party to the within action and, my [home/work address is [write your home/work address].

I transmitted to [party name] the following document(s) – [document name], as per the Rule [rule number].

The duplicate machine used by me complied with Rule [rule number], and no inaccuracy was reported by the machine. And, as per the Rule [rule number], I affected the machine to print a record of the transmission, a copy of which is enclosed with this declaration.

Executed on [date form was signed on], at [City, State].

I announce under perjury penalty, under the laws of the State of [state name] that the above said is true and correct.